1. The document discusses programmatic management of drug-resistant tuberculosis (DR-TB), specifically multi-drug resistant TB (MDR-TB). 2. MDR-TB is defined as TB resistant to both isoniazid and rifampicin, with or without resistance to other drugs. It poses a significant problem as patients who fail treatment have a high risk of death. 3. The epidemiology of MDR-TB in Zambia is described, noting about 1,500 cases annually. Risk factors for development of MDR-TB include poor compliance, physician error, lack of drugs, and failures in TB control programs.

1. N D O L A T E A C H I N G H O S P I T A L - C B U - S O M ,
I N T E R N A L M E D I C I N E
M A Y 2 0 2 2
PROGRAMMATIC MANAGEMENT OF DR-TB
Dr C Nyirenda

2. Learning objectives
 At the end of this unit the student will be able to:
1. Define MDR-TB
2. List the etiopathogenesis of MDR-TB
3. Understand the epidemiology of MDR-TB
4. Describe the pathophysiology of MDR-TB
5. Identify the clinical manifestations of MDR-TB
6. List the complications of MDR-TB
7. Describe the appropriate investigations for the
diagnosis of MDR-TB
8. Basic management of MDR-TB
9. Advise on a follow-up schedule for cases of MDR-TB

3. Introduction
 MDR-TB is defined as strains of M. tuberculosis
resistant to both isoniazid and rifampicin with or
without resistance to other drugs.
 MDR-TB is worrisome because patients that fail
treatment have a high risk of death.

4. Epidemiology of DR-TB
 MDR-TB is a growing problem in Zambia
 About 1,500 MDR/rifampicin resistant TB (RR-TB)
patients among notified PTB patients in Zambia (WHO
Global TB Report,2015)
 MDR/RR-TB prevalence among new and previously treated
TB patients was 1.1% and 18% respectively

5. PMDT
 PMDT structure, a multidisciplinary framework
including:
 Clinicians, lab personnel, pharmacists, programme
managers, community health workers, monitoring
and evaluation managers, supporting partners,
procurement and supply chain managers
 Others; regulatory authorities, civil society and DR-
TB patients

6. PMDT history in Zambia
 Initially one site, the UTH in Lusaka followed by the
NTH
 The two sites are now referral centres catering for
the southern and northern zones respectively
 Services now decentralized to include provincial
hospitals

7. DOTS
 Remains at the heart of the Stop TB Strategy
The basic components include:
 Political commitment with increased and sustained
financing
 Case detection through quality assured bacteriology
 Standardized tx with supervision and patient support
 An effective drug supply and mx system
 Monitoring and Evaluation system and impact
measurement

8. Directly Observed Therapy
 Ensure cure for the patient
 Ensure adherence to the treatment
 Patient required to take every dose of the
recommended treatment regimen
 In DOT supervisor watches the patient swallowing
his tablets, thereby ascertaining adherence to
treatment

9. Isoniazid, rifampicin
 Isoniazid is the most powerful mycobactericidal drug
available.
 Ensures early sputum conversion and helps in
decreasing transmission of TB.
 Rifampicin, by its mycobactericidal and sterilising
activities is crucial for preventing relapses.

10. Defn cont
 Thus these two drugs are keystone drugs in the
management of TB.
 Resistance to either isoniazid or rifampicin can be
managed with other 1st line drugs.
 Resistance to both demands treatment with 2nd line
drugs.

11. MDR - TB
Acquired resistance
 A form of MDR-TB caused by previous incomplete or
inadequate treatment
Primary resistance
 Acquiring a strain of TB that has already acquired
resistance

12. RESISTANCE IN CLINICAL PRACTICE
 Causes include;
Poor compliance
Physician error
Lack of drugs
Malabsorption
Failure of TB control program
Lack of lab diagnostic facilities

13. Case Finding
 All newly diagnosed re-treatment patients
 TB patients who remain sputum smear-positive after
2months
 Symptomatic close contact of confirmed DR-TB
patients
 Symptomatic individuals from high risk groups e.g.
health care workers, lab staff, prisoners

14. DIAGNOSIS
Labs
 DST: most reliable for R and H, less for km and Fq
 GXP positive R resistant-will be referred to start
MDR-TB treatment but await confirmation
 LPA is a confirmatory diagnosis
 Res to R and H, followed by DST for Fq and
Injectable
Additional work-ups
 CXR
 CT scan

15. MANAGEMENT cont..
 Treatment for MDR-TB should never be given on an
intermittent basis.
 The average recommended duration is two years for
the long term regimen.
 The duration for the short term regimen is 11 months
 2nd line are generally considered to be less effective
than the 1st line drugs and show a greater frequency
of adverse reactions.
 Less well tolerated.

16. Management cont.
 Use at least 4 effective drugs, never used b4 or
susceptible by DST
 Drug selection-Use Z and evaluate E; both not
counted among the effective
 One newer generation Fq (mfx or high dose lfx-in
adults
 One injectable ( Am )

18. Long treatment regimen
STANDARDIZED LONGER TREATMENT REGIMEN (FULLY ALL ORAL
OPTIONS)

19. Short term regimen
 4-6 Amikacin, Moxifloxacin, Clofazimine,
Ethionamide, Pyrazinamide, Ethambutol, High Dose
Isoniazid/ 5 Moxifloxacin, Clofazimine, Pyrazinamide,
Ethambutol (4–6 Am-Mfx-Cfz-Eto-Z-E-HHD / 5
Mfx-Cfz-E-Z)
 Add vitamin B6

20. END…
 Q/Cs??